Need Help with Est. Level-- Need to today please


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Help Please this is an est patient. Thank you for your time.

Patient with a history of medically complicated obesity, HTN and type 2 diabtes, presenting for weight loss surgery evaluation. Patient has failed multiple attempts of weight loss using conventional methods: dieting, exercising, and commercial weight loss programs. Underwent a 6 month physician supervised weight loss program and meets criteria for bariatric surgery.

Reports significant fatigue for the past few years that interferes with optimal performance of daily activities; however, the patient has noticed significant improvement with lifestyle changes in the past few months.

Current medication g3
Medication List Reconciled[].
Farxiga 5 mg tablet take 1 tablet (5 mg) by oral route once daily in the morning[].
Lantus Solostar 100 unit/mL (3 mL) insulin pen inject 36 Units by Subcutaneous route 1 time per day at bedtime[].
Lisinopril 20 mg tablet take 1 tablet by Oral route 1 time per day[].
Lipitor 10 mg tablet 1 tablet by Oral route 1 time per day[].
Amlodipine 10 mg tablet take 1 tablet (10 mg) by oral route once daily[].
Metformin 1,000 mg tablet extended release 24hr take 1 tablet by Oral route 2 times per day[].
BD Insulin Pen Needle UF Mini 31 x 3/16 " needle INJECT 1 Needle by Subcutaneous route 4 times per day[].
Humalog KwikPen 100 unit/mL insulin pen inject 12-24 units by Subcutaneous route 3 times per day before eating[].
Thiamine mononitrate 100 mg tablet 1 tablet by Oral route 1 time per day[].
One-Touch Ultra Test Strips strip TEST 1 Strip by Subcutaneous route 4 times per day Test as directed[].
CPAP Mask & Supplies CPAP of 16 cm H20, full face mask comfort size, large with humidification. DX:327.23 OSA[].eg

Past medical/surgical history g4
Surgical / Procedural: Prior surgery Vasectomy Dr. Benz
Circumcision 2010 Dr. Barriocanal
Type 2 diabetes mellitus insulin[].
Headache syndromes Migraines[]
Migraine headache[].
Sleep Apnea[].
? Otolaryngologic surgery[]
? Sinus surgery[]
? Tonsillectomy[]
? Orthopedic surgery hand[]eg

Review of systems g16
Systemic: Recent weight loss[].
Feeling tired or poorly[]. No fever[] and no chills[].
Head: No headache[].
Neck: No swollen glands in the neck[].
Eyes: No vision problems[] and no blurred vision[].
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion[]. Snoring[]. No sore throat[].
Cardiovascular: No chest pain or discomfort[] and no palpitations[].
Pulmonary: No shortness of breath[]. No cough[].
Gastrointestinal: No dysphagia[], no jaundice[], no change in stool[], no bright red blood per rectum[], no fecal incontinence[], and no polyphagia[]. No heartburn[]. No nausea[], no vomiting[], no diarrhea[], and no constipation[].
Genitourinary: No inguinal swelling[] and no increase in urinary frequency[]. No dysuria[].
Endocrine: No polydipsia[], no temperature intolerance[], and no hot flashes[].
Hematologic: No easy bleeding[] and no tendency for easy bruising[].
Musculoskeletal: No muscle aches[], no soft tissue stiffness -muscle stiffness[], and no limb pain[].
Arthralgias[]. No soft tissue swelling[]. Stiffness localized to one or more joints[].
Neurological: No memory lapses or loss[], no dizziness[], and no sensory disturbances[].
Psychological: Sleep apnea[]. No anxiety[] and no depression[]. Sleep disturbances[].
Skin: No pruritus[] and no rash[].
Urinary System: Bladder incontinence was not demonstrated[].eg

Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature[] 98 10/02/2015
RR[] 18 per min 10/02/2015
PR[] 94 bpm 10/02/2015
Blood pressure[] 148/80 mmHg 10/02/2015
Pain level by numeric rating scale[] 0 10/02/2015
Weight[] 380 lbs 10/02/2015
Body mass index[] 54.5 kg/m2 10/02/2015
Height[] 70 in 10/02/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area[] 2.9 10/02/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation[] 97% percent 10/02/2015
Standard Measurements:
? Patient was observed to be obese[].
General Appearance:
? Alert[].
? Eyes:[]
Visual Inspection: ? Abdomen was normal on visual inspection[]. ? Abdomen was not distended[].
Palpation: ? No ascites[]. ? Abdomen was soft[]. ? Abdominal non-tender[]. ? No mass was palpated in the abdomen[].
Liver: ? Not enlarged[].
? Oriented to time, place, and person[].
Mood: ? Not depressed[]. ? Not anxious[].
? Showed no generalized erythema[]. ? No skin lesions[].
Cardiovascular Disorder:
? Lymphedema[].
Orthopedic Disorder:
? Backache[].
Gastrointestinal Disorder:
? No hernia[].eg

Assessment g11
? Lethargy was observed[]
? Morbid obesity due to excess calories[]
? Type 2 diabetes mellitus without complication[]
? Hypertension[]
? Sleep apnea[]
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. Based criteria, the patient is a good candidate for bariatric surgery. After discussing all the different types of procedures, the patient would like to proceed with a laparoscopic vertical sleeve gastrectomy and possible hiatal hernia repair.
All possible risk and complications, including but not limited to staple line leak or bleeding (2%), sleeve gastrectomy stricture (5%), cardiopulmonary and thromboembolic complications, stroke, infection, malnutrition and weight regain were discussed in detail.
Vitamin levels reviewed. Cardiac and psychological clearances were obtained.

Allergies and Adverse Reactions g24
Gabapentin 300 mg capsule. Reaction(s): Upset Stomach, Vomiting. Date Identified: 04/13/2015[].
Allergies Reviewed[].eg

Plan g13
? CBC with differential[]
? Basic metabolic panel with total calcium[]
? Serum vitamin D3 (cholecalciferol)[]
? Follow-up visit 10 day(s)[]
1) Bariatric Liquid Diet 1 week before surgery
2) Discontinue all diuretics 1 week before surgery
3) Discharge instructions and postoperative medication prescriptions provided
4) EKG
5) Follow Up 1 week postoperatively

Last edited:


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This was difficult to read but I come up with a 99214. History appears to be comprehensive, exam I get EPF with 95, MDM I get moderate.

There appears to be conflicting information though. It says no hernia but they may fix a hernia?

Hope this helps,



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Can you explain the moderate? I was thinking low since the fatigue it getting better and the weight is stable. I see the hypertension but it is never address. Don't know if its stable or what.

Thank you for your time.


Nashville, TN
Best answers
Can you explain the moderate? I was thinking low since the fatigue it getting better and the weight is stable. I see the hypertension but it is never address. Don't know if its stable or what.

Thank you for your time.
I got Low for the MDM as well. The patient isn't being treated for the HTN, etc.